Provider Demographics
NPI:1336338433
Name:GUPTA, NIDHI (MD)
Entity Type:Individual
Prefix:
First Name:NIDHI
Middle Name:
Last Name:GUPTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 2ND ST SE
Mailing Address - Street 2:
Mailing Address - City:PINE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55063-1704
Mailing Address - Country:US
Mailing Address - Phone:320-629-6721
Mailing Address - Fax:
Practice Address - Street 1:510 2ND ST SE
Practice Address - Street 2:
Practice Address - City:PINE CITY
Practice Address - State:MN
Practice Address - Zip Code:55063-1704
Practice Address - Country:US
Practice Address - Phone:320-629-6721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-15
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301089993207R00000X
MN52785207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine